Reflections of a Dietetic Intern Through the Inaugural WVU ISPP Class

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March is National Nutrition Month and it has been a process in the making at developing a campaign for such an important month to the professional of dietetics! As an intern, I have worked with the entire staff at the facility that I am rotating at currently at, and there are a number of events, activities, and education that we have planned for this month.

MyPlate March Madness:
– Employees register for a month-long MyPlate cornhole tournament and particpate during their lunch hour in the multipurpose room within the facility. The winner at the end of the month will receive a healthy cookbook and cooking tips as well!

West Virginia Ramps:
– Nutritional information, cultural background, cooking use, and growth information will be provided to clients, patients, and employees at the facility. I collaborated with another staff member at developing the content.

NNM 2014 Table Tents:
– I developed these table tents with the NNM 2014 logo as well as “Nutrition 101” questions and answers at the bottom of each side of the table tents. Then I put these on display in the facility’s public eating area for everyone to see! This gives this specific population a boost of nutrition knowledge all throughout the month!

March Mediterranean Lunch ‘n Learn:
– This event will incorporate cooking skills, food culture, and nutritional benefits-like heart health. I assisted in the development and implementation of the event and this will take place at the end of the month, as a 1-hour event in a multipurpose room within the facility as well. Participants will learn how to create easy, affordable, and creative appetizers, dips, and spreads. I’ll even give you a hint- kale chips will have a BIG role in this delicious event as well!

The Commission on Dietetics Registration (CDR) defines continuing professional education (CPE) as education beyond that required for entry into the profession of nutrition and dietetics. CPE participation is mandatory for maintenance of registration. CDR Credentialed Practitioners engage in lifelong development to maintain and improve knowledge and skills for competent practice. This includes continuous self-assessments to identify professional strengths and learning needs, establishment of short-term and long-term goals for individual professional development and selection of appropriate CPE to meet these goals.

Prior approved activities are individual educational activities for which activity Providers have opted to request continuing professional education (CPE) hour approval on behalf of CDR Credentialed Practitioners prior to the date of the activity.

The documentation for review to the CDR or the affiliated dietetic association should be submitted 4-6 weeks prior to the activity date. The CDR requests at least 4-6 weeks for review and asks that the applicant keeps one copy for their file. Some affiliate dietetic associations share the CPE approval responsibilities with the CDR.

Live Activities
The CDR or State CPE Review Contact will send verification of approval. Activity Providers MUST provide each participant with a certificate of completion verifying completion of the activity. Providers MUST also maintain a list of participants who completed their activity for at least 7 years. The approval status can be effective up to one calendar year from date of approval. Approval status will expire after the 1st of the year, and the entire activity along with documentation must be resubmitted for review prior to the expiration date.

The following must be provided with Prior Approval Requests:
– Educational objectives, describing anticipated outcomes for each session
– A Timing outline, detailing all the time spent in sessions, meals, breaks, testing, etc. All hours are awarded for learning time only
– Info regarding the target audience
– Qualifications of speaker(s)/presenter(s).

Self Study Activities
Request for Prior Approval of Self-Study activities must be submitted to the CDR for review. Providers MUST also maintain a list of participants who completed their activity for at least 7 years. The approval status can be effective up to one calendar year from date of approval. Approval status will expire after the third year, and the entire activity along with documentation must be resubmitted for review prior to the expiration date. The CDR’s Competency Assurance Panel has ruled that Self Study CPE activities, regardless of their format, will be eligible for CPE credit for up to 3 years from the date of their initial publication. PDP (Professional Development Portfolio) policy had until recently indicated that Self Study activities which were not “enduring”, like newspapers and recording of live presentations, would be eligible for CPE credit for only 1 year.

The following must be provided with Prior Approval Requests:
– Access to Self Study activities, including objectives of the activity stated in operational behavioral terms
– A bibliography for reference and further reading. Complete references must be cited. Controversial or disputed issues must be presented as such, with documentation from current and reputable refereed scientific journals
– Three letters from content experts. Letters should attest to the CPE content appropriateness for the CDR credentialed practitioners with specific comments. The letters should also attest to the length of time required to complete the activity. The content experts should not be associated with the Provider in any way. A biography, resume, or CV must be included for each content
– Documentation of the background in test item development of the item writers (participation in class, workshops on item writing techniques including sponsoring organization’s name)

As a part of one of my major projects for my currently rotation site, they have asked me to present a CPE presentation/webinar to be streamed to other affiliated hospitals on the FODMAP diet. The FODMAP diet is currently a presentation assignment/project of mine for my Graduate Seminar class this semester. So, hopefully my Seminar presentation, on March 25th, goes well and I can work out any kinks before I plan on presenting at my rotation site facility. So, be on the lookout for a blog about the FODMAP diet!

Intradialytic parenteral nutrition is the infusion of an intravenous nutritional formula of hyperalimentation (artificial supplements of nutrients), like amino acids, glucose, and lipids, during dialysis to treat protein calorie malnutrition in an effort to decrease the associated morbidity and mortality experienced in patients with renal failure or end-stage renal disease (ESRD). The term “parenteral” refers to administration of medication or fluid other than through the digestive tract (intravenous or intramuscular).

Protein calorie malnutrition, typically assessed by measurements of serum albumin, occurs in an estimated 25–40% of those undergoing dialysis and is associated with increased morbidity and mortality. For example, the risk of death is increased more than 10-fold in those whose serum albumin levels are less than 2.5 g/dL, and those with a serum albumin near the normal range have a mortality rate twice as high as those with albumin greater than 4.0 g/dL.

In patients receiving chronic dialysis, the National Kidney Foundation currently recommends a daily protein intake of equal to or greater than 1.2 g/kg in patients undergoing hemodialysis and equal to or greater than 1.3 g/kg in patients undergoing peritoneal dialysis. In hemodialysis, the intradialytic IDPN infusion is administered through the venous port of the dialysis tubing, typically, 30 minutes after dialysis has begun, and continued throughout the remainder of a dialysis session. In peritoneal dialysis, sometimes referred to as intraperitoneal parenteral nutrition (IPPN) or intraperitoneal nutrition (IP), parenteral nutrition is infused into the peritoneal cavity during peritoneal dialysis.

Patients with ESRD on chronic hemodialysis have a high incidence of protein-energy malnutrition (PEM). The reasons for this are multi-factorial and include: inadequate food intake, a catabolic response to systemic illness or chronic inflammation, loss of nutrients through the dialysis procedure, as well as systemic effects of the uremic milieu. IDPN has been supported for the management of malnutrition in hemodialysis patients. The rationale for its use is that patients are unable to increase oral intake to meet their nutritional needs or that the oral or enteral route is not effective in managing malnutrition in this group of patients. Nevertheless, numerous studies using IDPN have failed to demonstrate efficacy conclusively with this very costly mode of treatment.

So, this being said… Today I had the opportunity to witness and assist in the methodology regarding how the Clinical Manager at my rotation site approves or possibly denies a patient request for IDPN. Currently, the cost for this request would approximately be $7,000 per month for a patient to receive IDPN, which is three times per week. So, my job today was to determine if this patient is eligible for the hospital to provide IDPN and how to justify the approval/deny request to hospital administrators as well.

Below are the criteria that I researched which is currently being used for the approval/denial of IDPN:

Patient must demonstrate the following:
– Failed attempt to increase nutritional status with oral nutritional supplements
– Is not a candidate for tubefeeding (where nasogastric or gastronomy feeding is unsafe or impractical)
– Is able to meet greater than or equal to 50% of needs orally

Sample IDPN prescription
Initiated after 30 minutes into the dialysis session, through the venous port of the dialysis tubing and given for the duration of the hemodialysis procedure (3.5 hours) at a rate of 150 ml/hour.

Amyotrophic lateral sclerosis (ALS), also known as “Lou Gehrig’s Disease,” is a progressive neurodegenerative disease that affects nerve cells in the brain and the spinal cord. Motor neurons reach from the brain to the spinal cord and from the spinal cord to the muscles throughout the body. The progressive degeneration of the motor neurons in ALS eventually leads to their death. When the motor neurons die, the ability of the brain to initiate and control muscle movement is lost. With voluntary muscle action progressively affected, patients in the later stages of the disease may become totally paralyzed.

There is early evidence from a small study that people with ALS who are fed a high-kcal, high-carb diet, could potentially see the progression of their disease slowed.
Patients with ALS, who have difficulty swallowing, as did the 24 people in this study, often end up requiring a feeding tube into the stomach in order to receive the adequate amount of nutrition. These patients are usually fed a standard commercially available formula. ALS patient lose weight because they are not able to take in enough calories because of their difficulty in swallowing. As patients lose weight, they are actually burning their own muscle.

Researchers found that a high-kcal, high-carb tube-fed diet was safe and tolerated- better than one designed to main weight or a diet high in fat. Patients on the high-kcal, high-carb diet gained some of the weight they had lost. At the very least, patients should avoid losing weight.

There needs to be larger trials to see if patients should be trying to gain weight. But, until this happens, all patients with ALS should be actively avoiding losing weight.
This study was published in February 2014 and experts report that the results are far from definitive. This study is also much too small to really show a survival benefit from the diets described. A larger trial would be needed to really highlight any problems. Overall, the study, and future studies, would be beneficial if it included more patients.

CAD is the most common type of heart disease. In the United States, it is the #1 cause of death for both men and women. Lifestyle changes, medicines, and medical procedures can help prevent or treat CAD. These treatments may reduce the risk of related health problems. CAD happens when the arteries that supply blood to heart muscle become hardened and narrowed. This is due to the buildup of cholesterol and plaque, on the inner walls. This buildup is called atherosclerosis. As it grows, less blood can flow through the arteries. As a result, the heart muscle can’t get the blood or oxygen it needs. This can lead to chest pain (angina) or worse. Most heart attacks happen when a blood clot suddenly cuts off the hearts’ blood supply, causing permanent heart damage.

A patient seen today was admitted in the intesive care unit (ICU) and was referred to the nutrition staff for support in cardiac care.

Background:
The patient experienced a myocardial infarction (MI) and had coronary artery disease (CAD). He was a male, 85 y/o, and admitted for an MI protocol. He was currently on a cardiac diet with no gastric irritants (NGI). NGIs are foods like juices, chili, and black pepper. He was not experiencing shortness of breathe (SOB), nausea, fever, chills, or vomiting.

Familial hypertriglyceridemia is a common disorder passed down through families in which the levels of triglycerides in a person’s blood are higher than normal. This condition is not associated with a significant increase in cholesterol levels. Recently I had the opportunity to assist in the treatment of a patient who suffered from familial hypertriglyceridemia. I’m glad I had the opportunity to take part in this case because I really learned a lot from this patient, his conditions, and how all of the components in life can affect the rest of your life and health.

The patient was a male, 39 years of age, and was suffering from hypertriglyceridemia. His condition was also exacerbated by his weight, insulin resistance, and alcohol consumption. The patient’s peripheral vascular disease raised suspicion for familial dysbetalipoproteinema. The gentleman was a non-traditional student at a nearby college, majoring in mechanical engineering. He was also married with two daughters. The patient was the main food preparer in the household and was open and willing to learn new ways of cooking (low-fat) for his family.

So after speaking with the patient, learning his diet habits, and hearing about his lifestyle factors, as well as other miscellaneous habits, we developed a few goals for him to strive for.
Goal 1: The patient mentioned that he drinks 2-3 cans of soda a week. So, we asked if he can cut that out of his diet. And he said he could.
Goal 2: The patient mentioned that he’s very tech savvy so we asked if he could keep a food log on through a Smart phone application. And he said he could.

It was clear to me that the patient was at risk for developing pancreatitis from the amount of pressure that his pancreas was experiencing from the fat in his diet. So, to avoid this, we recommended that the patient restrict his fat intake to 15% of his daily energy intake. This is a good starting point for this patient. This way we can work together to get his fat (and protein) levels down and take those important baby steps towards decreasing his fat intake even more, hopefully, in the future.

The facility that I am currently rotating at asked me to assist in preparing a women’s heart health event using resources from the facility’s women’s clinic as well as another Registered Dietitian. So, with the help of WVU’s Extension Service Love Your Heart Movement, I prepared a PowerPoint presentation on women’s heart health and the importance of keeping West Virginia’s women healthy.

Of course, on Tuesday, West Virginia was hit with another spell of bad weather. So, not as many participants could attend. But we still had a very good turnout. I led the presentation with the majority of the information coming from another Love Your Heart Movement presentation, but I also incorporated some tables and graphs from the Center of Disease Control and Prevention (CDC) as well as tips from the American Heart Association’s Life’s Simple 7.

Midway through the presentation a Registered Dietitian had an activity showing the differences between healthy fats and unhealthy fats. Some healthy fats that were displayed were walnuts, almonds, and canned tuna fish. Some unhealthy fats that were shown were butter and Crisco. This was done to show the difference between the health risks/benefits between solid fats and liquid fats as well.

We prepared for this presentation for weeks. And I’m really glad that I assisted with it because the women’s clinic at this facility is considered a special population due to the high volume of male patients they attend to. The participants seemed very engaged and willing to make those small steps towards becoming heart healthy!

I’d also like to say thank you to WVU’s Extension Service Love Your Heart Movement for not only providing the supplies, handouts, and supplemental information from one of their Extension Agents but also for providing the magnets and pins we gave the participants as incentives. The participants loved the items and information and we’re hoping for an even bigger event next year!

Pro-Stat is a nutritional supplement that I recently became familiar with at my MNT rotations. This supplement is used for patients who are having difficulties gaining weight or consuming energy, in general. This supplement delivers the highest concentration of protein and calories in the smallest serving size. It is ideal for patients with an increased need for protein, have a poor appetite, suffer from pressure ulcers, or who could be experiencing protein-energy malnutrition. Pro-Stat is a complete protein and contains all the essential amino acids while being easy to administer. There is no mixing required and I witnessed the supplement being used with a patient who was on a tube feeding. The patient didn’t seem to mind the supplement, which is rare. A large number of patients who are on tube feedings seem to be very particular about what supplements or formula they are consuming. So, it was to my surprise that the patient who we introduced this supplement to, actually seemed like he enjoyed the protein supplement. Plus, I think it helped that I explained to the patient why we were giving him the supplement and how it would help his health status too.

A nasogastric (NG) tube is a special tube that carries food and medicine to the stomach through the nose. It can be used for all feedings or for giving your patient/client extra calories. It’s important to take good care of the feeding bag and tubing so that they work properly, as well as the skin around the nostrils so that it does not get irritated.NG tube feedings incorporate a procedure where a thin, plastic tube is inserted through the nostril, down the esophagus, and into the stomach. Once the NG tube is in place, healthcare providers can deliver food and medicine directly to the stomach or remove substances from it.

NG tube feeding has four distinct advantages:

·Short-term (<4 weeks)

·Most commonly used

·Easiest to place (with a prior patient assessment)

·Least expensive to administer

Nasogastric tubes are used mainly for short-term support in patients who do not have problems like vomiting, GERD, poor gastric emptying, ileus or intestinal obstruction. Nasogastric tubes can be used for longer term support where other enteral access is not possible or could potentially carry a risk. NG tubes are potentially dangerous in patients who cannot swallow correctly and those who need to be nursed. A patient assessment should always be carried out prior to placement of an NG tube. NG tubes are placed by appropriately trained staff like nurses or doctors.

There is a small risk that NG tubes can be misplaced on insertion or move out of position at a later stage. Position of NG tubes should be verified on initial placement and before each use. It is recommended that a pH <5.5 is consistent with gastric placement. If aspirate cannot be obtained or the pH is >5.5 feeding should not begin. The NG tube should be left in place, the patient’s position changed and the aspirate re-tested in 1 hour. The feed itself can increase the pH in the stomach, so aspiration should take place at least 1 hour after the feed has been stopped.

When a patient cannot eat any or enough food because of an illness or health complication, sometimes other forms of nutrition are required to assist the patient towards better health. The stomach or bowel may not be working normally, or a person may have had surgery to remove part or all of these organs. When this occurs, and a patient or client is unable to eat, nutrition must be supplied in a different way. One method that can be applied is Parenteral Nutrition.

Parenteral Nutrition bypasses the normal digestion in the stomach and bowel. It is a special liquid food mixture given into the blood through an intravenous (IV) catheter (needle in the vein). The mixture contains proteins, carbohydrates, lipids, vitamins and minerals. This special mixture may be called Parenteral Nutrition or Total Parenteral Nutrition (TPN).

A special IV catheter will be placed in a large vein in the chest or arm. It can stay in place for as long as needed. Proper care is required to avoid infection and clotting. Different kinds of catheters may be used. Common types of catheters are Peripherally Inserted Central Catheter (PICC), triple lumen, double lumen, or single lumen catheters, and Ports. Nutrition is given through this large vein. Coordinated care, consisting of doctors, nurses, RDs, and pharmacists, will talk with the patient about the different types of catheters prior to administering anything.

Prior to initiating TPN, a nutrition assessment is necessary to determine nutrient needs and to anticipate any metabolic changes that may occur due to the patient’s underlying condition, medications or concurrent therapies, etc. Important factors to consider when assessing a patient for TPN are: